<form id="edit-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Presentation_patient_char_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-presentation_patient_char_id" data-rule="required" data-source="presentation/patient/char/index" class="form-control selectpage form-control" name="row[presentation_patient_char_id]" type="text" value="{$row.presentation_patient_char_id}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Name_of_drug_as_reported')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-name_of_drug_as_reported" class="form-control form-control" name="row[name_of_drug_as_reported]" type="text" value="{$row.name_of_drug_as_reported}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Mpid_version_date_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-mpid_version_date_number" class="form-control form-control" name="row[mpid_version_date_number]" type="text" value="{$row.mpid_version_date_number}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Medicinal_product_identifier_mpid')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-medicinal_product_identifier_mpid" class="form-control form-control" name="row[medicinal_product_identifier_mpid]" type="text" value="{$row.medicinal_product_identifier_mpid}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Phpid_version_date_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-phpid_version_date_number" class="form-control form-control" name="row[phpid_version_date_number]" type="text" value="{$row.phpid_version_date_number}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Pharmaceutical_product_identifier_phpid')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-pharmaceutical_product_identifier_phpid" class="form-control form-control" name="row[pharmaceutical_product_identifier_phpid]" type="text" value="{$row.pharmaceutical_product_identifier_phpid}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Start_date')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-start_date" class="form-control datetimepicker form-control"  data-date-format="YYYY-MM-DD" data-use-current="true" name="row[start_date]" type="text" value="{$row.start_date}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('End_date')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-end_date" class="form-control datetimepicker form-control"  data-date-format="YYYY-MM-DD" data-use-current="true" name="row[end_date]" type="text" value="{$row.end_date}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Meddra_version_for_indication')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-meddra_version_for_indication" class="form-control   form-control"
                   name="row[meddra_version_for_indication]" type="number" value="{$row.meddra_version_for_indication}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Indication_meddra_code')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-indication_meddra_code" class="form-control  selectpage  form-control"
                   data-source="meddra/index" data-show-field="en" data-show-field="en" data-primary-key="code"
                   name="row[indication_meddra_code]" type="text" value="{$row.indication_meddra_code}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Meddra_version_for_reaction')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-meddra_version_for_reaction" class="form-control form-control" name="row[meddra_version_for_reaction]" type="number" value="{$row.meddra_version_for_reaction}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Reaction_meddra_code')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-reaction_meddra_code" class="form-control  selectpage form-control"
                   data-source="meddra/index" data-show-field="en" data-show-field="en" data-primary-key="code"
                   name="row[reaction_meddra_code]" type="text" value="{$row.reaction_meddra_code}">
        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-success btn-embossed disabled">{:__('OK')}</button>
            <button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
        </div>
    </div>
</form>
